AAFP Journal Airs Debate over Group's Coke Sponsorship

Controversy over the American Academy of Family Physicians' acceptance of grant money from the Coca-Cola Company is continuing -- this time in the pages of the group's own journal.

Last October, the AAFP announced that it would accept a grant from Coke to "develop consumer education content on beverages and sweeteners for FamilyDoctor.org," a consumer health website operated by the group.

That set off a storm of criticism from consumer advocates and medical-ethics groups who argued that the relationship was a major conflict of interest for the AAFP. Critics said the group's acceptance of the Coke money sent the wrong message at a time when it should be counseling children and their parents to avoid soft drinks and other sugar-sweetened beverages.

The July/August issue of the Annals of Family Medicine -- one of several publications sponsored by the AAFP -- carries an essay by Howard Brody, MD, PhD, of the University of Texas Medical Branch in Galveston, attacking the Coke arrangement. The essay is accompanied by a rebuttal from the group's president, Lori Heim, MD.

Brody argued that the deal is unquestionably a conflict of interest for the AAFP and that it may foretell "the development of a corporate culture within a medical professional society."

Noting that the AAFP had indicated that it hoped to develop additional programs with commercial sponsors, Brody suggested that these arrangements would insidiously undermine "its duty to the public health and public trust."

But Heim insisted that nothing like that had happened -- or would happen -- as a result of the AAFP's acceptance of corporate funding for its educational programs.

"Brody himself acknowledges, 'It is true that where a conflict of interest exists, no actual unethical behavior has necessarily arisen. There may be a strong temptation to serve a competing interest instead of doing one's duty, and yet one may have successfully withstood the temptation.' The actions of the [AAFP] with regard to the Coca-Cola Company agreement have, indeed, proven this point," she wrote.

"Simply entering into the Consumer Alliance Program with [Coke] does not define further behavior by the AAFP," Heim contended. She indicated that the contract with Coke stipulates that the AAFP would control the FamilyDoctor.org content, with outside peer review and no implied or explicit product endorsement.

She asserted that the material on the FamilyDoctor.org site indicated that the AAFP "scrupulously adhered to its core principles," and offered samples in which the website recommends limiting foods and beverages with added sugar.

"FamilyDoctor.org has won numerous national awards for its service as a clearinghouse of evidence-based and peer-reviewed information about healthful living; the symptoms, diagnosis, and treatment of illness; and patients' communication with their primary care physicians and healthcare team," she indicated.

"These are the facts. They are not a rationalization," Heim added. "Simply because these facts do not comport with others' perceptions or projected motivations does not mean they constitute a conflict of interest or an ethical breach," she wrote.

But Brody argued that conflicts of interest are inherent in the relationship, regardless of whether there is hard evidence that the relationship actually altered behavior. The current content of FamilyDoctor.org is irrelevant, he suggested.

"If the final educational material includes a strong statement against sugary soft drinks, we will never know whether, absent the Coca-Cola funding, the statement would have been even stronger. That such questions will inevitably be raised shows the conflict of interest is both present and serious, quite apart from the eventual contents of the educational materials," Brody wrote.

Consequently, Heim's argument that no ill effect from the Coke funding can be discerned in the FamilyDoctor.org content is a rationalization, Brody insisted.

A more valid argument from the AAFP, according to Brody, is its position that apparent conflicts of interest can be addressed by disclosure and proper management, such that no actual conflict occurs and the organization continues to act ethically.

As Heim put it, "AAFP consistently addresses possible conflict of interest openly and directly, sharing with our members and the public exactly what measures we take to ensure that, in fact, no unethical conduct or breach of trust would -- or will in the future -- occur."

But Brody indicated that this "Management Strategy" would inevitably come up short.

"'Apparent' conflicts of interest challenge public trust in medicine and hence are, in fact, conflicts of interest," he asserted. "The Management Strategy sets a low bar for compliance and hence is less satisfactory than a Divestment Strategy [avoiding conflicted relationships altogether] for an organization that aspires to higher ethical standards of conduct," Brody wrote.

He also worried that a medical society accepting such relationships may become dependent on the income from them.

"Over time, its leaders come to decide that a certain revenue stream is 'necessary' for the organization to function, and then notes that it is unable to maintain that amount of revenue without generous funding from commercial sources," he wrote.

"An organization that develops such a corporate culture may be poorly situated to address the ethical challenges raised by conflict of interest and to place its duty to the public health and public trust at a proper level of priority," Brody concluded.

Brody indicated that he is a member of the AAFP and declared he had no other conflicts of interest.

Heim is president of the AAFP and declared no other conflicts of interest.

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